Larissa MacFarquhar: Paying for Kidneys

In this week’s issue, Larissa MacFarquhar writes about people who donate their kidneys to strangers. (Subscribers can access the entire article online.) These donors were motivated by altruism. But what about people who might be willing to part with a kidney for money?

Legalizing payment for organs is a ferociously controversial topic in the organ world. Opponents fear exploitation—that the poor will become organ suppliers for the rich. (“You can imagine a scenario where someone would say, ‘Welfare? You’ve still got two kidneys!’ the political philosopher Peter Lawler has said. “There would be the expectation that your kidney might be understood as part of your net wealth.”) It is presumably true that most organ sellers would be poor; on the other hand, many of the recipients would be poor also. Others worry that paid donors would have a motive to lie about aspects of their medical history that might cause a transplant center to reject them, and it’s true that while many kidney-related problems can be tested for, some crucial ones can be hidden—a family history of kidney disease or diabetes, for instance, or an individual history of kidney stones or drug abuse. The National Kidney Foundation opposes compensation on the grounds that it would “cheapen the gift”—that it may be an “affront” to those who have already donated. (“The argument that paying organ donors is ‘an affront’ to unpaid donors is disgusting,” Virginia Postrel, who donated a kidney to her acquaintance Sally Satel, wrote on her website. “Are unpaid donors giving organs to save lives or just to make themselves feel morally superior?”)

In countries where organ-selling is widespread, though illegal—Pakistan, India, the Philippines—organ sellers are often worse off after surgery, physically and even financially, because they may be cheated out of their payments, and because inadequate follow-up care often leaves them unable to work. Opponents of legalization often cite this fact, though it is of questionable relevance, since living donors in the U.S. are, statistically, as healthy after surgery as anybody else. It is not clear what impact the legalization of kidney sales in the U.S. would have on illegal organ trafficking abroad. Presumably most Americans who would have become organ tourists would prefer to obtain a kidney legally at home; on the other hand, some believe that the American ban on sales is an important moral bulwark against more organ selling in places where even legalization would not mean safety.

It is often assumed that at least permitting compensation for kidneys would result in more living donors, but this is not necessarily the case. Under the current system, a person who needs a kidney will usually turn to his family, and possibly his friends, for help, but if he could obtain a kidney from a stranger, paid for by his insurance, would he ask a person he loved to undertake the nuisance and risk of surgery? (Of course, this assumes that there would be enough kidney sellers to supply the need.) In Israel, where until recently the practice of transplant tourism—going abroad to receive a kidney transplant—was widely accepted, donations from living relatives were relatively rare. It seems likely, too, that the sort of person who might now donate to a stranger for altruistic reasons would not do so if the donation were a commercial proposition (one altruistic donor asks compensation proponents to consider whether an offer of cash from a boyfriend would increase the probability that the girlfriend would have sex with him)—though there are so few altruistic donors that their numbers don’t much affect the calculus.

As things are now, usually around six thousand living Americans donate kidneys each year. Would more people than that donate for money? It is legal to pay surrogate mothers for their time, effort, and suffering, but the demand for them outstrips the supply: there are approximately a thousand surrogate births each year in this country. Of course, donating a kidney is much less time-consuming and emotionally fraught than being a surrogate mother; human egg donation is probably a better comparison, though donating eggs doesn’t require major surgery, with its risks and recovery time. There are no official statistics on how many women donate eggs, but, in 2003, the Centers for Disease Control and Prevention counted just under thirteen thousand embryo transfers involving donated eggs. The pool of potential kidney donors is obviously larger than that for reproductive medicine—men can give kidneys, and kidney patients don’t tend to care about the hair color and S.A.T. scores of their donors. But if—a big if—compensation were restricted to Americans, it does not seem certain that the number of compensated kidney donors would be much greater than the number of volunteers.

Larissa MacFarquhar has been a staff writer at The New Yorker since 1998.